Specialised Services Service Specification: CP29b ... Bariatric Surgery... · management of post-surgical complications, including the availability of 24- hour consultant bariatric

Specialised Services

Service Specification: CP29b

Bariatric Surgery

August 2018

Version 1.0

Welsh Health Specialised Services Committee (WHSSC) August 2018

Document information

Document purpose Service Specification

Document name Bariatric Surgery Service Specification

Author Welsh Health Specialised Services Committee

Publication date 04 October 2018

Commissioning Team Cardiac

Target audience Chief Executives, Medical Directors, Directors of

Finance, Chief Pharmacists

Description NHS Wales will routinely commission this

specialised service in accordance with the criteria

described in this policy

Document No CP29b

Review Date March 2020

Service Specification: CP29b, Bariatric Surgery


Contents

Statement ............................................................................ 4

1. Introduction ..................................................................... 5

1.1 Background .............................................................. 5

1.2 Aims and Objectives of the service .............................. 5 1.3 Relationship with other documents .............................. 6

2. Service Delivery ................................................................ 7

2.1 Access Criteria .......................................................... 7 2.2 Service description .................................................... 8

Facilities and equipment .................................................. 8

Staffing ......................................................................... 8

Specialist teams ............................................................. 9

Clinical Standards .......................................................... 9

2.3 Exclusion Criteria ..................................................... 12 2.4 Acceptance Criteria ................................................... 13

2.5 Patient Pathway (Annex i) ......................................... 13 2.6 Service provider/Designated Centre ............................ 13

2.7 Exceptions ............................................................... 14

3. Quality and Patient Safety ................................................. 15

3.1 National Standards ................................................... 15 3.2 Other quality requirements ........................................ 15

4. Performance monitoring and Information Requirement ......... 16

4.1 Performance Monitoring ............................................ 16 4.2 Key Performance Indicators ....................................... 16

4.3 Date of Review ......................................................... 17

5. Equality Impact and Assessment ........................................ 18

6. Putting Things Right: Raising a Concern .............................. 19

Annex i Patient Pathway ..................................................... 20

Annex ii Codes ................................................................... 21

Annex iii Abbreviations and Glossary ..................................... 22



Statement

Welsh Health Specialised Services Committee (WHSSC) will commission the service of Bariatric Surgery in accordance with the criteria outlined in this

document.

In creating this document WHSSC has reviewed the requirements and standards of care that are expected to deliver this service.

Disclaimer

WHSSC assumes that healthcare professionals will use their clinical

judgment, knowledge and expertise when deciding whether it is appropriate to apply this document.

This document may not be clinically appropriate for use in all situations and

does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in

consultation with the patient and/or their carer or guardian.

WHSSC disclaims any responsibility for damages arising out of the use or non-use of this document.



1. Introduction

This policy has been developed as the Service Specification for the planning and delivery of Bariatric Surgery for Adults aged 18 years and older and

resident in Wales. This service will only be commissioned by the Welsh Specialised Services Committee (WHSSC) and applies to residents of all

seven Health Boards in Wales.

1.1 Background

Bariatric surgery is a treatment for appropriate, selected patients with severe and complex obesity that has not responded to all other non-

invasive therapies. Within these patient groups bariatric surgery has also been shown to be a highly cost effective therapy that prevents the

development of co-morbidities and reduce the symptoms of existing co-morbidities, particularly type 2 diabetes.

This sits under Tier 4 of the weight management pathway. Different tiers of weight management cover different activities, and definitions vary locally

but essentially correspond with the following:

Tier 1 provides universal services (such as health promotion or

primary care) Tier 2 provides lifestyle interventions

Tier 3 provides specialist weight management services Tier 4 provides bariatric surgery.

The surgery is known to achieve significant and sustainable weight reduction within 1-2 years, as well as reductions in co-morbidities and

mortality. The principal bariatric operations are gastric banding, gastric bypass, sleeve gastrectomy and duodenal switch. These are usually

undertaken laparoscopically.

1.2 Aims and Objectives of the service

The aim of this service is to define the requirements and standard of care

essential for delivering bariatric surgery for people with severe and complex obesity that has not responded to all other non-invasive

therapies.

The objectives of this policy are to:

detail the specifications required to deliver bariatric services for

people who are residents in Wales

ensure minimum standards of care are met for the use of bariatric surgery

ensure equitable access to bariatric surgery identify centres that are able to provide bariatric surgery for Welsh

patients improve outcomes for people accessing bariatric surgery services



1.3 Relationship with other documents

This document should be read in conjunction with the following

documents:

NHS Wales o All Wales Policy: Making Decisions in Individual Patient Funding

requests (IPFR).

WHSSC policies and service specifications o Commissioning Policy: Bariatric Surgery CP29a, (2014) f

Other published documents

o BOMSS Standards for Clinical Services and Guidance on Commissioning (2012).

o BOMSS Professional Standards Document (2013).

http://www.wales.nhs.uk/governance-emanual/individual-patient-funding-requests

http://www.wales.nhs.uk/governance-emanual/individual-patient-funding-requests

http://www.whssc.wales.nhs.uk/sitesplus/documents/1119/CP29%20Bariatric%20Surgery%20Commissioning%20Policy%20v3%2001.pdf


about:blank

about:blank

http://www.bomss.org.uk/wp-content/uploads/2014/04/BOMSS-Professional-Standards-March-2013.pdf



2. Service Delivery

The Welsh Health Specialised Services Committee will commission the service of bariatric surgery for welsh residents with severe or complex obesity, in-line with the criteria identified in the policy.

Surgery to aid weight reduction for adults with morbid/severe obesity

should be considered when there is recent and comprehensive evidence that:

an individual patient has fully engaged in a structured weight loss programme

all appropriate non-invasive measures have been tried continuously and for a sufficient period but have failed to achieve

and maintain a clinically significant weight loss for the patients clinical needs (NICE, Obesity: Identification, assessment and

management, Clinical Guideline CG189 (2014) recommendations1).

the patient should in addition to the above have been adequately counselled and prepared for bariatric surgery.

Whilst bariatric surgery is a last-line intervention, the provision of follow up for complications, nutritional and weight maintenance support for the

patient remains a lifetime commitment for the patient.

2.1 Access Criteria

Individuals must satisfy all elements of the access criteria set out below:

the individual is aged 18 years or over

the individual has a BMI of 40 or greater

morbid/severe obesity has been present for at least five years

the individual has received, and complied with, an intensive weight management programme at a multi-disciplinary weight

management clinic (level 2/3 of the All Wales Obesity Pathway) for at least 24 months duration, but has been unable to achieve

and maintain a healthy weight, and

the individual is approved for surgery by the bariatric MDT at the

Welsh Institute of Metabolic and Obesity Surgery, Abertawe Bro Morgannwg University Health Board.

For further information see:

WHSSC commissioning policy for Bariatric Surgery (CP29a)

1 Obesity: identification, assessment and management | Guidance and guidelines | NICE


https://www.nice.org.uk/guidance/cg189



2.2 Service description

In addition to the standards required within the Contract, specific quality standards and measures will be expected. The provider must also meet

the standards as set out below.

Facilities and equipment

Providers of complex obesity services must be able to demonstrate that

they have suitably equipped facilities and appropriately trained specialist staff to provide assessment, pre-operative, operative, and post-operative

care for patients.

The service should have a physical environment that meets the needs of

patient attending the service: toilet seats, grab rails, shower chairs, commodes, chairs, beds, lifting equipment etc. will be suitable for use by

patients who are morbidly obese. The provider will make appropriate beds and scales available for obese patients, and ensure that suitable imaging

equipment is available for obese patients.

The surgical service should have demonstrable arrangements for:

• access to in-patient beds for post-operative recovery

• access to critical care facilities 24 hours a day, to at least high dependency (HDU) Level 2, and located on the same site at which

surgical procedures are undertaken • access to Intensive Care Unit (ICU) Level 3 facilities on sites where

surgical procedures are undertaken that are available 24 hours a day. Where this is not the case providers will have robust plans and

procedures in place for patient transfers to local ICU level 3 critical care facilities that are available 24 hours a day. Procedures will

include details of arrangements that the provider has with the receiving hospital for clinical liaison hand-over during the patient

transfer and post transfer/re-admittance to their surgical unit

Ideally, facilities for the complex obesity service will be separate from those

for other patients in order to maintain the focus of the service on the special

needs of the patients. However, irrespective of whether there are dedicated facilities, providers will ensure that privacy and dignity of patients is

maintained at all times.

Staffing

The surgical service should have demonstrable arrangements for:

access to suitably qualified doctor with sufficient training and experience in bariatric surgery 24 hours a day for advice and

treatment as necessary the emergency assessment and treatment of post-operative

complications provision for revisional procedures following assessment of previous

outcomes for primary bariatric surgery



the training and education of all staff involved in the care and

management of morbidly obese patients.

Specialist teams

The specialist surgical multidisciplinary team (MDT) should include as a

minimum:

Clinical Nurse Specialist

Bariatric surgeon

Bariatric dietician

Specialist anaesthetist

Relevant medical specialist with an interest in obesity e.g. endocrinologist/diabetologist

Psychotherapist / Psychologist / Psychiatrist with an interest in obesity

This list is not exhaustive and the MDT should have access to/include the most appropriate group of health care professionals required to make a

comprehensive and appropriate decision and ideally on site access to other relevant medical specialists for the diagnosis and management of co-

morbidities.

The bariatric surgery MDT will meet physically (rather than virtually) where possible, and minutes will be recorded of the patient management

decisions.

The surgical MDT will be supported by a radiologist with a special interest in gastro-intestinal surgery.

If input is required in the immediate post-operative recovery period,

patients will have access to all members of multi-disciplinary team, e.g.

physiotherapists & occupational therapists. The service must have in place a clear communication process with local services where on-going

treatments / interventions are required post discharge.

Clinical Standards

The provider centre will deliver primary bariatric surgery for all patients

deemed clinically appropriate and within the criteria defined in the commissioning policy.

The MDT will assess the patient to determine:

the cause of obesity

the presence and severity of co-morbidities

to stratify/score risk



to evaluate the modalities of weight loss that have been explored

to detect other diseases and

to optimise their medical condition.

The bariatric surgery MDT will satisfy itself that the overall risk: benefit

evaluation favours bariatric surgery, and that the patient meets the access criteria for Bariatric Surgery as stated in the WHSSC Commissioning Policy:

CP29: Bariatric Surgery (2014).

The bariatric surgery MDT will satisfy itself that the patient is likely to engage in the follow up programme that is required after any bariatric

surgical procedure to ensure:

safety of the patient

best clinical outcome is obtained and then maintained

change in eating behaviour

change in physical behaviour

change in health promoting lifestyle

Surgery

The bariatric surgery centre will be able to provide the full range of routine

bariatric procedures, including laparoscopic and open procedures and revisional procedures. The appropriate procedure carried will be agreed

between the Multi-Disciplinary Team (MDT) and the patient. Providers will not restrict practice to one single method of operation.

It is expected that laparoscopic surgery will be the normal operating

method used.

Out of Hours

The bariatric surgery centre will be able to provide 24-hour emergency

management of post-surgical complications, including the availability of 24-

hour consultant bariatric surgeon cover or joint cover with upper GI surgeons. In some models of care the surgical bariatric service is part of

the wider general surgery division and is clinically integrated with the upper GI surgical service.

The critical factor is rapid access to bariatric surgery advice and attendance.

Services will also have appropriate on-site arrangements for critical care of the morbidly obese together with suitably trained and qualified staff to

support this area.

Consultant Surgeons

Bariatric units will have a minimum of 3 consultant surgeons. Each surgeon

will perform on average at least 40 procedures per annum (1 a week).



However the general trend is that more patients a unit operates on, the

higher the quality. This is dealt with in more detail in the BOMSS Standards for Clinical Services and Guidance on Commissioning (2012)2.

The surgeons in the multidisciplinary team should be adequately trained

and experienced in the recognition and management of bariatric surgery complications (see BOMSS Professional Standards Document 20133).

Patient Support

The Tier 4 bariatric surgery provider will be able to offer support to patients through a designated contact person and in the form of a clear and

comprehensive information pack in appropriate formats to comply with equality and diversity legislation.

The provider will work with, and support, patients to set up and maintain

patient support groups and also sign post patients to other patient support

groups facilitated by different organisations or charities. Such groups are a vital source of peer support, advice and information for patients. They may

also be able, depending on their stage of development, to form an advocacy role, either at group or individual level, or as agents for change or service

development. Members of the bariatric surgery MDT will attend at the request of the patients group to provide professional advice and input as

appropriate.

Providers must enable the patient’s, carer’s and advocate’s informed participation and to be able to demonstrate this. Provision should be made

for patients with communication difficulties.

Follow Up

The provision of after-care and weight management support for the patient

remains a lifetime commitment. Structured, systematic and team based

follow up will be organised by the bariatric surgery provider for 2 years after surgery.

The follow up care should include regular, specialist post-operative dietetic

and /or specialist nurse monitoring according to patient need. Clinical follow up should mirror post –operative information and should include:

information on the appropriate diet for the bariatric procedure

micronutrient monitoring and supplementation

information on patient support groups

2 BOMSS standards for clinical services | BOMSS 3 http://www.bomss.org.uk/wp-content/uploads/2014/04/BOMSS-Professional-

Standards-March-2013.pdf

http://www.bomss.org.uk/bomss-standards-for-clinical-services/





individualised support and guidance to achieve long–term weight loss

and monitor weight maintenance

Patients should be made aware of the requirement to engage in the 2 year Tier 4 follow up programme.

After 2 years, patients will be transferred back to their GP and local Tier 3

services in order to continue to have access to dietetic, clinical behavioural and, psychological advice and support to help them modify their lifestyle to

maintain weight loss/reduction and to prevent or minimise complications. However, as stated previously in this document, this section of the

pathway is not completely developed at the current time within Wales.

Follow up arrangements will however be procedure specific and for certain

procedures there will always be a need for specialist follow up by the

specialised services provider.

The specialised service will at all times maintain links with the patients’ local services ensuring that they are aware of the patient’s ongoing

progress.

The care of post-operative complications and delayed emergencies

Patients must be provided with clear advice regarding recognition of post-

operative complications and the time frame on which complications/emergencies may occur.

The bariatric service must ensure appropriate telephone advice is available

to professionals at other hospitals and facilitate the return of the patients where this will improve care. The service must have appropriate pathways

in place to manage the transfer and repatriation of patients back to the Tier

4 service.

2.3 Exclusion Criteria

Referrals from the NHS for the revision of treatments originally performed outside the NHS will not be funded. This includes gastric

band fills, outpatient follow up and revision surgery. Referrers should refer the patient to the practitioner who carried out the original

treatment.

Referrals for patients who have undergone emergency corrective

treatment in the NHS following treatment originally performed outside the NHS, but who go on and request further NHS funded

revision, will be assessed against the eligibility criteria.

Plastic surgery, which may be required as a result of weight loss

following bariatric surgery. (Clinicians wishing to refer patients for



plastic surgery post bariatric surgery will be required to make a

referral to plastic surgery. The patient will have to meet the criteria for access to plastic surgery in order for the surgery to be funded).

and

Individuals under 18 years of age.

2.4 Acceptance Criteria

The service outlined in this specification is for patients ordinarily resident in Wales, or otherwise the commissioning responsibility of the NHS in

Wales. This excludes patients who whilst resident in Wales, are registered with a GP practice in England, but includes patients resident in England who

are registered with a GP Practice in Wales.

2.5 Patient Pathway (Annex i)

In Wales LHBs are currently working on plans to implement the All Wales

Obesity Pathway. There is a particular gap in relation to Tier 3 services,

which, when fully developed, will develop close links with, and will gate-keep referrals to, the bariatric surgery service.

In the interim and whilst gaps remain, referrals to the bariatric Multi-Disciplinary Team at the Tier 4 provider centre will be made according to

the referral pathway designated by each LHB for its resident population.

The Bariatric Surgery centre will have clinical protocols and programmes of

care that deal with the patient journey through assessment, medical or surgical intervention, post-surgical care (where appropriate), discharge and

long term follow up. This includes the transition back to Primary Care, and specifically a specialist weight management service local to the patient’s

home (where available), as part of a life-long shared care arrangement of follow-up and surveillance.

The centre will be required to demonstrate that they have multi-disciplinary teams that can provide such assessments and that clinically appropriate

referrals to other specialties for further consultation and clinical

management will be made.

2.6 Service provider/Designated Centre

The bariatric surgery service for Wales is provided by the following

organisations:

For patients resident in South and Mid Wales:

Welsh Institute for Metabolic and Obesity Surgery

Abertawe Bro Morgannwg University Health Board

For patients resident in North Wales

Salford Royal NHS Foundation Trust



2.7 Exceptions

If the patient does not meet the criteria for treatment as outlined in this policy, an Individual Patient Funding Request (IPFR) can be submitted for

consideration in line with the All Wales Policy: Making Decisions on

Individual Patient Funding Requests. The request will then be considered by the All Wales IPFR Panel.

If the patient wishes to be referred to a provider outside of the agreed

pathway, and IPFR should be submitted.

Further information on making IPFR requests can be found at: Welsh Health Specialised Services Committee (WHSSC) | Individual Patient Funding

Requests

http://www.whssc.wales.nhs.uk/individual-patient-funding-requests





3. Quality and Patient Safety

The provider must work to written quality standards and provide monitoring information to the lead commissioner. The quality management systems

must be externally audited and accredited.

The centre must enable the patients, carers and advocates informed participation and to be able to demonstrate this. Provision should be made

for patients with communication difficulties.

3.1 National Standards

The provider must work to the following quality standards:

British Obesity and Metabolic Surgery Society Service Standards

(2012)

Providers will submit their outcome data to the National Bariatric Surgery Registry.

3.2 Other quality requirements

the provider will have a recognised system to demonstrate service quality and standards

the service will have detailed clinical protocols setting out nationally (and local where appropriate) recognised good practice

the quality system and its treatment protocols will be subject to

regular clinical and management audit

the provider is required to undertake regular patient surveys and

develop and implement an action plan based on findings



4. Performance monitoring and Information Requirement

4.1 Performance Monitoring

WHSSC will be responsible for commissioning services in line with this

policy. This will include agreeing appropriate information and procedures to monitor the performance of organisations.

For the services defined in this policy the following approach will be adopted:

Service providers to evidence quality and performance controls

Service providers to evidence compliance with standards of care

WHSSC will conduct performance and quality reviews on an annual basis.

4.2 Key Performance Indicators

The providers will be expected to monitor against the full list of Quality Indicators derived from the service description components described in

Section 2.2.

The provider should also monitor the appropriateness of referrals into the

service and provide regular feedback to referrers on inappropriate referrals, identifying any trends or potential educational needs.

In particular, the provider will be expected to monitor against the following target outcomes:

Post-operative mortality Post-operative complications

Post-surgical weight Loss

Co-morbidity Improvement Patient experience

Quality of Life

Every month providers should send to WHSSC by email waiting times performance and activity (number of operations by case mix) performance.

It is the provider’s responsibility to notify WHSSC as the commissioner

should there be any breaches of the waiting times targets.

These should be submitted to WHSSC monthly on the 10th working day of the month.

Waiting times profile of the patients on the bariatric surgery waiting list

(from time of addition to the in-patient surgical waiting list):

0-9 weeks 10-25 weeks

26-35 weeks >=36 weeks



Surgical activity, out-patient and in-patient (operations), will be reported

to WHSSC on a monthly basis. In-patient activity will be reported by type of operation.

4.3 Date of Review

This document is scheduled for review before March 2020 where we will

check if any new evidence is available.

If an update is carried out the policy will remain extant until the revised policy is published.



5. Equality Impact and Assessment

The Equality Impact Assessment (EQIA) process has been developed to help promote fair and equal treatment in the delivery of health services. It

aims to enable Welsh Health Specialised Services Committee to identify and eliminate detrimental treatment caused by the adverse impact of health

service policies upon groups and individuals for reasons of race, gender re-assignment, disability, sex, sexual orientation, age, religion and belief,

marriage and civil partnership, pregnancy and maternity and language

(Welsh).

This policy has been subjected to an Equality Impact Assessment.

The Assessment demonstrates the policy is robust and there is no potential for discrimination or adverse impact. All opportunities to promote equality

have been taken.



6. Putting Things Right: Raising a Concern

If the patient does not meet the criteria for treatment as outlined in this policy, an Individual Patient Funding Request (IPFR) can be submitted for

consideration in line with the All Wales Policy: Making Decisions on Individual Patient Funding Requests. The request will then be considered

by the All Wales IPFR Panel.

If an IPFR is declined by the Panel, a patient and/or their NHS clinician has

the right to request information about how the decision was reached. If the patient and their NHS clinician feel the process has not been followed in

accordance with this policy, arrangements can be made for an independent review of the process to be undertaken by the patient’s Local Health Board.

The ground for the review, which are detailed in the All Wales Policy: Making Decisions on Individual Patient Funding Requests (IPFR), must be

clearly stated

If the patient wishes to be referred to a provider outside of the agreed pathway, and IPFR should be submitted.

Further information on making IPFR requests can be found at: Welsh Health

Specialised Services Committee (WHSSC) | Individual Patient Funding Requests






Annex i Patient Pathway

Local weight management services (Tiers 1 to 3).

Referral Tier 4 (Welsh Institute of Metabolic and Obesity Surgery – WIMOS) via LHB gatekeeper for

assessment against the commissioning policy

WIMOS: does the referral meet the access criteria set out in the commissioning policy?

Out-patient assessment: Is the patient suitable for

bariatric surgery?

Referral back to local weight management

services.

Admission for surgery

Follow-up:

Short term (2 yrs): bariatric surgery service.

Long term: Local weight management services

Yes No

Yes

No



Annex ii Codes

The following ICD-10 and OPCS 4 codes define obesity and bariatric surgery.

ICD-10 Codes

Code Category Code Description

ICD10 E66 Obesity

OPCS 4 Codes

Code Category Code Description

OPCS4 G282 Partial gastrectomy and

anastomosis of stomach to

transposed jejunum

OPCS4 G283 Partial gastrectomy and

anastomosis of stomach to jejunum NEC

OPCS4 G288 Other specified partial excision of

stomach

OPCS4 G289 Unspecified partial excision of

stomach

OPCS4 G301 Gastroplasty NEC

OPCS4 G302 Partitioning of stomach NEC

OPCS4 G303 Partitioning of stomach using band

OPCS4 G304 Partitioning of stomach using staples

OPCS4 G308 Other specified plastic operations on stomach

OPCS4 G309 Unspecified plastic operations on

stomach

OPCS4 G321 Bypass of stomach by anastomosis

of stomach to transposed jejunum

OPCS4 G328 Other specified connection of stomach to transposed jejunum

OPCS4 G329 Unspecified connection of stomach to transposed jejunum

OPCS4 G611 Bypass of jejunum by anastomosis

of jejunum to jejunum


of jejunum to ileum


of jejunum to colon

OPCS4 G618 Other specified bypass of jejunum

OPCS4 G619 Unspecified bypass of jejunum



Annex iii Abbreviations and Glossary

Abbreviations

BOMSS British Obesity and Metabolic Surgery Society

MDT Multidisciplinary Team

Glossary

Individual Patient Funding Request (IPFR)

An IPFR is a request to Welsh Health Specialised Services Committee

(WHSSC) to fund an intervention, device or treatment for patients that fall outside the range of services and treatments routinely provided across

Wales.

Welsh Health Specialised Services Committee (WHSSC) WHSSC is a joint committee of the seven local health boards in Wales. The

purpose of WHSSC is to ensure that the population of Wales has fair and equitable access to the full range of Specialised Services and Tertiary

Services. WHSSC ensures that specialised services are commissioned from providers that have the appropriate experience and expertise. They ensure

that these providers are able to provide a robust, high quality and sustainable services, which are safe for patients and are cost effective for

NHS Wales.

Documents

Specialised Services Service Specification: CP29b ... Bariatric Surgery... · management of post-surgical complications, including the availability of 24- hour consultant bariatric